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Reducing the burden on hospital services

13 September 2012 | By Hilary Thomas

Professor Hilary Thomas looks at the coming together of community services and the movement of cash flow.

Last week we focused on the movement of data in community services. While that is critical for the coming together of community services, perhaps even more fundamental is the need for money and financial incentives to align, ensuring community services reduce the burden on the hospital front door.

It isn’t a huge leap to move from discussions about the movement of data to that of cash flow as many of the principles outlined in relation to data also apply to the movement of money around the system. After all, a common taxonomy and agreed way to record information will both be required for the money to follow the patient and incentivise the right changes. As justifiable as it was to paraphrase Bill Clinton’s campaign phrase when discussing data, the same should be said for cash flow: “It’s the system, stupid”.

Of course, one of the big question is how money flows between health and social care. Writing in HSJ in May, Thomas Hughes-Hallett, the outgoing chief executive of Marie Curie commented that “the lack of integration between health and social care services can restrict innovation, but innovations in social care can realise savings in healthcare and vice versa”. His point should not be lost because unlocking this challenge is critical for the transformational changes many community services will require.

It isn’t just about using social care staff more effectively to make a step change in skill-mixes; what also counts is enabling community staff to be more effectively leveraged, so they are able to supervise larger groups of patients. You only have to look at the effect had when Marie Curie work with forward looking commissioners. They seem able to overcome this challenge to enable more people to move from hospital to home to receive end of life care where they want it.

Technology is a further powerful enabler that we have been woefully inadequate at using as we can’t seem to spend the money in an effective way to change the way the service wraps around the patient. Some health economies, for example, have purchased kit but have not effected the service redesign and change management to capitalise on it.

The real challenge in making this work is in designing pathways around patients, end-to-end, and working with staff and patients to ensure these new pathways are adopted and diffused - the two biggest challenges to any innovation. From the patient’s perspective care should be seamless, irrespective of the organisational forms involved and should be based around clinical leadership. Of course, the clinical leadership need not rest within the organisation which takes the lead on the pathway.

Yet it’s not all bad. Where the system, as a complete entity, really works well it seems that strong relationships exists on the ground across multiple organisations. Without breaking them, the teams on the ground overcome any issues created by the rules and regulations to simply do the best for the patient. This is further helped by co-location - and the adaptation of many of our tired, community facilities to offer fit for purpose 21st century care will be key to ensure success.

Put simply, if emerging commissioners are unable to move money around the system to make this happen smoothly and motivate all parties to cooperate, change will only happen in pockets and be less effective than anyone would hope - or expect - to see.

And it is at this point that strong leadership really matters. Leaders will be important in agreeing how bundles of care, rather than interventions, can be supported - removing the historical pull of the hospital. It won’t be easy because to achieve this will require a culture shift - not only for social or community care, but also for the health professionals in the system.

Individuals characteristically default to being loyal to their employing organisation so some investment in working out how money needs to flow through the system to support the patient but also, ultimately, to do more with less, is more than necessary. It must happen so we can genuinely move away from a system which is focused on payment for activity to one which looks at outcomes - and it will require starting small pilots, which can then be grown.

That’s not to say we should be starting from scratch as there are already models of integrated care emerging around the country. Some have been fostered by pooling resources and ensuring hospitals are supported during the transition. However, strong personal leadership by hospital-based clinicians is also essential to oversee community delivered models - and where this exists already, there are some very good news stories. The unfortunate thing, now though, is that this often happens in spite of the way money flows and to make it real across wider geographies will require a leap of faith and some bold changes to the way care is commissioned.

Perhaps some particularly courageous localities will be able to develop from personalised budgets to delivering models of care where patients themselves can help to innovate. The self-care model of renal dialysis in Jonkoping was designed by a patient and, at Guy’s, home dialysis at night grew thanks to motivated patients. That principle could be extended in community services. Indeed I suspect most renal dialysis will be delivered in community-based settings within a decade.

If the cash doesn’t flow smoothly to enable this to happen services in the UK will fall behind those of other European nations. We cannot afford to let that happen and some disruptive innovation will be required in community services to really transform the type of care and how it is delivered. Success will need brave commissioners, leadership and vision. Getting it right could make patient’s lives better and greatly enhance the job satisfaction of those delivering care.

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